Extramural Registration
2008-2009

Please complete this form and sign at the bottom to give your child permission to participate in the soccer intramural/extramural activity for this year.

Emergency Information In order that we may provide for the safety of your child during the intramural/extramural program, please complete the following information.  Please print in ink.

STUDENT NAME AGE GRADE _________________________________

HOME PHONE CELL PHONE __________________________________

MOTHER'S NAME WORK PHONE __________________________________

FATHER'S NAME WORK PHONE __________________________________

FAMILY DOCTOR PHONE __________________________________

WHO TO CONTACT IF YOU CANNOT BE REACHED BY PHONE __________________________________

In the event of an emergency or accident and I cannot be reached, I give permission for a school representative or ambulance to transport this student to ______________________ Hospital, family doctor or other emergency facility and to authorize emergency medical treatment.  In the event of extreme emergency, the closest doctor or medical facility may be utilized.  I will assume full responsibility for all charges related to the above and release the school, the hospital, and the Fulton County School System, its agents, employees, administrators, and assigns from any and all liability claims and causes of action arising in connection with the transportation or treatment of the student named hereon.

Please note any medical problems, medication requirements, allergies and special instructions pertaining to this student:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________



The school system offers student accident insurance for a nominal fee.  This policy covers accidents that occur at any school sponsored activity, including intramurals and extramurals.  See Mr. Conrad for details.

Please sign below indicating your preference of coverage for your child.

My child, _______________, is enrolled in the Student Accident Insurance program offered through the school for the 2008-2009 school year.


Parent's Signature Date
                                    

                                    -OR-


After reviewing the school's student insurance program, I hereby elect not to participate in that insurance program.  In making this decision I certifiy that I have insurance coverage for my child and will assume the liability for any accident or injury which may occur to my child in connection with his/her intramural or extramural participation.  I recognize that neither Fulton County Board of Education nor any employees of Fulton Science Academy can be responsible for medical expenses for any such accident or injury.


Parent's Signature Date


My child has permission to participate in the intramural and extramural program and the above information is complete and correct.


Parent's Signature _______________________________    Date _______________